Provider Demographics
NPI:1508075789
Name:NEAL, MARY BOYD (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BOYD
Last Name:NEAL
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:320 HIGH TIDE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-2323
Mailing Address - Country:US
Mailing Address - Phone:904-392-1704
Mailing Address - Fax:904-460-0068
Practice Address - Street 1:320 HIGH TIDE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-2323
Practice Address - Country:US
Practice Address - Phone:904-392-1704
Practice Address - Fax:904-460-0068
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2223106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL510603971OtherFEIN